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Case reports
metaplasia are shown in areas adjacent to the diverticula. The completely metaplastic ducts have the
same histological appearance as the diverticula. The
findings therefore strongly support the view that the
diverticula derive from and represent abnormal
mucous gland ducts.
Ten cases of intramural oesophageal diverticulosis have been reported in the literature. The
patients had all experienced dysphagia for many
years. Their ages ranged from 11 to 83 years, and
there was an equal sex distribution. The following
mechanisms of pathogenesis have been suggested :
(1) The diverticula represent mucosal herniations
through the muscularis mucosa, due to increased
oesophageal intraluminal pressure (Creely and
Trail, 1970; Weller and Lutzker, 1971; Weller,
1972; Mendl, Darragh Montgomery and Stephenson, 1973). This mechanism has been linked
to the development of Rokitansky-Aschoff
sinuses in the gall-bladder (Mendl et ah,
1960).
(2) The diverticula represent hypertrophied mucosal glands, secondary to low grade infection,
possibly due to Monilia (Hodes, Atkins and
Hodes, 1966; Troupin, 1968). Review of one
case suggested that deep ulcers due to monilial
oesophagitis had initially been mistaken for
intramural diverticula (Zatskin, Green and La
Vine, 1968; Smulewicz and Dorfman, 1971).
(3) They arise from the combined effects of increased pressure and chronic inflammation (Lane,
1972).
(4) They are congenital or developmental in origin
(Culver and Chaudhari, 1967).
Based on our histological findings, we suggest
the following pathogenesis. The oesophageal gland
ducts have undergone squamous metaplasia in
response to some chronic irritation {e.g., chemical,
The authors wish to thank Mr. A. J. Heriot for permission to publish this case.
REFERENCES
CREELY, J. J., and TRAIL, M. L., 1970. Intramural diverti-
Intramural diverticulosis of the oesophagus and Rokitansky-Aschoff sinuses in the gall-bladder. British Journal of
Radiology, 33, 496-501.
SMULEWICZ, J. J., and DORFMAN, J., 1971. Oesophageal
diverticulosis of the oesophagus associated with postoperative hiatal hernia, alkaline oesophagitis and oesophageal stricture. Radiology, 98, 213-211.
ZATSKIN, H. R., GREEN, S., and LA VINE, J. J., 1968.
498
AUGUST
1974
Case reports
A 19-year-old man was admitted to the University Hospital of the West Indies with a small bowel fistula which
followed an operation for the relief of intestinal obstruction
at another hospital. The fistula had appeared five days
after the operation and appeared to be from the jejunum.
He was cachectic, but there was no evidence of intestinal
obstruction and it was decided to manage the patient
by restriction of oral intake and hyperalimentation intravenously. Following two weeks of satisfactory progress with
hyperalimentation through a central catheter placed via
puncture of the right cephalic vein, he suddenly developed
high fever, tachycardia, jaundice and generalized pains. A
diagnosis of septicaemia was made, and blood cultures
grew coagulase-positive staphylococci. The central venous
line was removed and replaced by another, inserted by
puncture of the left subclavian vein. Appropriate antibiotic
and hyperalimentation therapy was continued. Six days
after the insertion of the new line his condition deteriorated
FIG. 1.
Six days after the insertion of a central venous catheter
there is consolidation translucency in the right middle and
lower zones.
FIG. 2.
The abscess cavity in the right lower zone showing contrast
medium pooling in the base of the abscess. Some pulmonary
artery branches are also opacified.
499
T. R., 1969. Air embolusa lethal complication of subclavian venepuncture. New England Journal of Medicine,
281, 488-489.
HENZEL, J. H., and DEWEESE, M. S., 1971. Morbid and
Case history
A boy of 17 was admitted to this hospital via the accident
department having sustained an injury to his right knee in a
motor cycle accident. An X ray of this knee revealed a haemarthrosis but no bony injury. It was however observed
that the appearance of the femur, tibia andfibula,and
particularly of the epiphyses was abnormal. A number of
other areas were therefore X rayed.
The most striking radiological changes are in the skull.
There is extreme cortical thickening of the vault, particularly in the frontal and basi-occipital regions. The base
of the skull is also thickened especially in the petrous area.
The maxilla is clearly affected. Unfortunately the mandible,
which is typically involved in this condition, was not
included.
500